距骨损伤与距骨坏死及其治疗

目的 探讨距骨损伤对距骨缺血坏死的影响及其治疗方法。方法 本文通过25例距骨重度骨折脱位、3例距骨全脱位和17例距骨周围脱位的治疗,并分别经平均7年和2年5个月的随访观察,来分析三种不同类型的损伤对距骨缺血坏死的影响。结果 距骨重度骨折脱位和全脱位缺血坏死率和创伤性关节炎发生率100％,距骨周围脱位则无缺血坏死发生。作者比较重度距骨骨折脱位和全脱位采用切开复位内固定、距骨切除和关系融合术三种治疗方法的结果,仅融合术最为满意。结论 作者建议在距骨有发生缺血坏死高危损伤的病例,融合术应是首选的方法。     

重度距骨骨折脱位和距骨周围脱位的治疗

本文作者报告了２８例重度距骨骨折脱位和１７例距骨周围脱位的治疗结果。分别平均随访为７年及２年５个月。作者比较了重度距骨骨折脱位的复位固定，距骨切除和关节融合三种方法的治疗结果，认为关节融合疗效确实可靠，应作为首选的治疗方法。距骨周围脱位在关节内有骨折碎块或有软组织嵌压时常是切开复位的适应证。创伤的严重性，合并关节内骨折和开放性损伤常是影响预后的因素。与重度距骨骨折脱位不同，该组病例无缺血坏死发生。     

距骨骨折后缺血坏死的相关因素分析

目的 :探讨距骨骨折类型和手术方式与骨折后坏死的关系。方法 :自2009年3月至2013年11月收治78例距骨骨折患者,43例随访2~5年,其中男27例,女16例;年龄17~65岁,平均38.6岁。39例距骨颈损伤,4例距骨体损伤。根据损伤情况采取前内侧、前外侧及联合入路手术等方法治疗,受伤后6~48 h进行治疗。分析患者前期骨折类型以及手术方式与后期骨坏死发生概率之间的关系。结果:78例中43例获随访,19例发生距骨坏死,包括距骨颈Ⅰ型骨折2例,距骨颈Ⅱ型骨折5例,距骨颈Ⅲ型骨折5例,距骨颈Ⅳ型骨折5例,距骨体骨折2例(均为合并距骨颈骨折的患者)。共29例采取手术治疗,采用不同手术方式治疗的患者发生距骨坏死的差异无统计学意义。结论:距骨颈骨折较距骨体骨折更易发生缺血坏死,在距骨颈骨折分型中,Ⅲ、Ⅳ型发生缺血坏死可能性大。     

血管植入术治疗距骨缺血坏死的临床分析

<正> 距骨缺血性坏死常发生距骨颈骨折伴脱位,坏死率较高。我院自1987～1997年收治距骨颈骨折脱位78例,经切开复位内固定术后,发生距骨缺血坏死13例,经采用钻孔血管植入术治疗,效果满意,现分析如下。     

距骨周围脱位的手术治疗

目的探讨距骨周围脱位的手术治疗方法与效果。方法对1999年至2011年收治的13例距骨周围脱位病例,其中手术治疗8例。结果所有8例患者均获得1～6年随访,平均1.5年。AOFAS评分77.6(58.3～96.7),但3例外侧型脱位评分较低,平均70.1。3例患者术后完全恢复。1例患者踝关节活动无明显受限,但感觉踝关节轻度不稳;2例踝关节活动功能部分受限,偶有疼痛;2例外侧型脱位患者关节僵硬,明显疼痛,无法行走,其中1例并发生距骨缺血性坏死,因疼痛行胫距距下关节融合术,术后疼痛缓解。结论对于闭合复位未能成功或复位不全的距骨周围脱位应及时手术切开复位,恢复距下关节的解剖完整性,获得准确的关节对位,避免后遗症。     

距骨骨折脱位32 例治疗

目的探讨距骨骨折及距骨与周围关节脱位的处理方法。方法1998年2月～2005年10月收治32例距骨骨折脱位。其中男23例,女9例;年龄19～56岁。车祸伤13例,坠落伤10例,压砸伤7例,扭伤2例。其中开放性损伤7例,伴同侧肢体或踝部骨折、韧带损伤10例,脾破裂1例。距骨颈骨折按Hawkins分类：型5例,型12例,型7例,型2例,距骨体骨折4例,距骨头骨折2例。伤后2～26h进行治疗。手术切开复位者以2枚螺丝钉内固定,距骨体粉碎性骨折者行距下关节融合术。结果32例均获随访6个月～7年,术后疗效按Kenwright4级分类法评定,闭合性复位7例,优5例,良2例;切开复位内固定14例,优6例,良3例,可3例,差2例;开放性损伤7例,优1例,良2例,可2例,差2例;距下关节融合术4例,优1例,良2例,可1例。结论距骨骨折或脱位后及时取得良好复位,恢复正确解剖关系对稳定足部非常重要,合理处理能最大限度恢复踝关节功能。     

距骨骨折脱位腓骨下端截骨向后翻转手术入路的应用

距骨骨折脱位是足部的一种常见的严重损伤,往在由于损伤使骨间血管,骨膜血管受损中断以及周围软组织的损伤或治疗不当导致预后不良,发生距骨缺血性坏死,其发生率据文献报告为16～71％。为此我们近三年来采用腓骨下端截骨向后翻转充分显露踝关节的手术入路方法,有效地克服了原常规手术入路而破坏距骨血供系统的缺点。我们在16例距骨骨折脱位手术治疗中采用上述手术入路,尽可能保护距骨血供系统取得了良好的效果。     

距骨骨折的治疗

目的:探讨距骨骨折的特点、分型、治疗方法及并发症防治。方法:1995年6月～2004年12月共治疗距骨骨折患者52例。根据Hawkins分型方法,Ⅰ型骨折8例,Ⅱ型骨折32例,Ⅲ型骨折10例。另有2例为距骨体骨折。Ⅰ型骨折行保守治疗;Ⅱ、Ⅲ、型骨折中,开放性骨折或伴有脱位的闭合骨折行急诊手术,解剖复位,松质骨拉力螺钉内固定;Ⅲ型骨折同时行距下关节一期融合。术后短腿石膏托或保护支具固定8～12周,并术后早期予CPM(持续被动活动)。至X线片示骨折愈合后逐渐负重。结果:46例获得随访,随访时间4月～5年,平均3.2年。按Howkins疗效标准:优14例(30.4%),良26例(56.5%),可4例(8.7%),差2例(4.3%);优良率为86.9%。术后发生距骨体坏死6例Ⅱ型骨折2例(发生坏死后行关节融合术),Ⅲ型骨折4例。另外,发生距骨下关节炎5例,其中3例合并踝关节炎。发生踝部皮肤坏死2例,伤口感染5例。结论:距骨骨折系高能创伤的结果,并发症多且后果严重,宜早期进行有效解剖复位和固定;术中应首先解决关节脱位,再进行骨折的复位和内固定。手术应力求简单,减少对局部软组织和血运的破坏和干扰,从而减少并发症的发生。术后进行早期功能康复有利用于功能的改善。     

陈旧性距骨颈骨折脱位的治疗

距骨颈骨折脱位是距骨的严重损伤，常并发距骨缺血性坏死和创伤性关节炎。而延误诊治的陈旧性距骨颈骨折脱位，不仅使处理的难度加大，而且对预后也产生严重的影响。本文就我院治疗的８例陈旧性距骨颈骨折脱位病人的治疗方法与疗效进行讨论。１临床资料１１一般资料８例...     

距骨骨折脱位的手术治疗(附27例报告)

本院自1990年1月~1996年5月共收治距骨骨折脱位病人49例,其中手术治疗27例。结果显示:①距骨骨折手术治疗的疗效与损伤程度和手术时间有密切联系。②严重距骨体骨折术后多发生创伤性关节炎。③严重距骨颈部骨折脱位术后多出现距骨缺血性坏死。     

Dislocations of the talus joints

With the exception of fracture dislocations following fractures of the ankle joint and talus, dislocations in the talus are very infrequent injuries. They pose a lot of management problems: soft-tissue damage in open and closed dislocations, imperfect reduction caused by osteochondral fragments, recurrent instability, and aseptic necrosis of the talus, which is greatly feared. Anatomical and prognostic criteria are included in a classification of mono-, bi- and triarticular dislocations of the talus. Based on six of our own cases treated in the last 12 months, we report the mechanisms of injury, management, and early results. In accordance with the results in the literature in the last few years, reconstruction of ligament damage and joint debridement were carried out in four cases and the results described. One case of open total dislocation of the talus is presented, which was complicated by a fracture of the calcaneus without traumatic avascular necrosis.     

Modified Blair Tibiotalar Arthrodesis for Post-traumatic Avascular Necrosis of the Talus: A Case Report

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.     

人工关节在踝关节残障中的应用及随访

[目的]观察植骨人工踝关节置换治疗踝关节病损的中远期疗效。[方法]自1998年10月～2008年12月,植骨人工踝关节置换治疗踝关节损伤性关节炎56例(其中伴距骨体顶部局限性坏死2例和胫骨骨折并小腿筋膜间室综合征广泛肌切除后距下关节融合1例),类风关1例。男35例,女22例;平均年龄54.7岁(28～68岁)。[结果]本组57例获平均6年9个月随访(2年10个月～10年3个月)。术前、术后踝关节功能采用Kofoed评价法和步态分析,术前踝关节功能62分(60～75)13例,47分(30～60)27例,16分(0～29)17例。术后效果优(85～100分)39例,良(75～84分)14例,差(60～74分)1例。优良率98.3%。术前、术后疗效按Kofoed评价以统计学分析,P<0.01具有显著意义。术前步态49例均为跛行步态(负重相>55%);术后正常步态(15%～45%周期内)24例,轻微跛行(站立相45%～55%)22例,跛行(负重相>55%)3例。未行步态分析8例。术前、术后步态分析两组数据的统计学分析P<0.05,有统计学意义。X线检查显示植骨部与假体间固定良好,植骨成活。[结论]植骨人工踝关节置换对...     

Reconstructive Surgery for Complete Talus Extrusion Using the Sandwich Block Arthrodesis: A Report of 2 Cases

Total extrusion of the talus is a rare and severe injury of the foot. If the talus is viable and can be repositioned, the outcome is unpredictable and mainly depends on whether infection and/or avascular necrosis ensues. If the talus is actually missing, the surgeon is faced with extensive bone loss and destruction of the ankle. In this report, we present 2 cases of total talus extrusion treated with the sandwich block tibiocalcaneal arthrodesis with structural autografts harvested from iliac crest. The surgical technique is reviewed in detail, and its application in 2 male patients who had a complete talus fracture-dislocation and a dislocation, respectively, is described. Follow-up after 18 years and 1 year, respectively, showed favorable clinical outcomes and only minor restrictions in daily activities. In light of these case reports, we believe that the sandwich block arthrodesis offers a useful alternative for the treatment of these serious lower extremity injuries.     

Primäre und sekundäre Arthrodesen nach Talusfrakturen

In 18 cases out of 55 patients, who had been operated on talus fractures in our clinic, a primary or secondary arthrodesis of one or both adjacent joints had been necessary. We carried out a follow-up examination on those 18 patients. In 4 cases a primary or early secondary arthrodesis had been performed; the attempt to reconstruct the joint surfaces after the trauma would have been not promising. The indication of the secondary arthrodesis in the 14 patients is discussed. In all the patients there had been a bony healing of the arthrodesis in an adequate time, the gait pattern of the patients had been improved and they complained less pain. We conclude that in case of a not solvable complication after talus fracture like destroyed joint surfaces, secondary severe arthritis or bone necrosis early secondary arthrodesis should be considered as a measurement to avoid long periods of insufficient conservative treatment.     

A Systematic Review of Total Dislocation of the Talus

This review summarizes the treatment and resulting outcomes for total talar dislocation. The PubMed database was searched for articles about humans with total talar dislocation published in the English language in the last twenty years. The following data were entered into a Microsoft Excel spreadsheet: type of dislocation, nature of associated fractures (if any), type of reduction/fixation utilized, immobilization, weight‐bearing status, outcome, complications and average follow‐up time. Thirty‐nine articles reporting a total of 86 cases of total talar dislocation are included in this review. Seventy‐three of these were open injuries and 13 closed. Forty‐three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. The talus was preserved in the initial management of 74 cases, whereas the remaining 12 cases were managed by primary talectomy. The mean duration of follow‐up was 32 months. Twenty‐two cases required a secondary arthrodesis or another additional procedure. A good outcome was achieved in 35% of cases, a fair outcome in 37% and a poor outcome in 27%. The complication of avascular necrosis (AVN) occurred in 22 cases and 14 subjects developed clinically significant osteoarthritis. Generally, the outcome of current treatments associated with total talar dislocation is not ideal, only 1/3 of cases achieving good outcomes. So far, preservation of the talus is the best treatment option. AVN is still a relatively common complication even in the absence of fracture or postoperative infection.     

Complete transverse fractures of the talus: value of magnetic resonance imaging for detection of avascular necrosis

The authors report a series of 32 complete transverse fractures of the neck or body of the talus. The fractures occurred mostly in young males, as a result of motor vehicle accidents. The fracture line was transverse in the neck or body of the talus in 20 cases, sagittal in four and comminuted in eight cases. Using Hawkins' classification, there were 10 type I, 16 type II, and 6 type III fractures. The treatment was conservative in 8 cases and surgical in 24. The patients were evaluated clinically and radiologically with an average follow-up of 7 years. All patients underwent radiological study at follow-up and 17 underwent NMR evaluation. Eleven underwent NMR evaluation at final follow-up, and the other 6 early in their postoperative evolution. The postoperative results were evaluated based upon clinical and radiological criteria. The clinical result was good or very good in 37.5% of cases. Segmental necrosis of the talar body was noted in 6 cases and complete necrosis in 5, which required arthrodesis in 8 cases. Avascular necrosis is a common complication. Its frequency depends on the type and displacement of the fracture. If it becomes symptomatic, the only treatment is tibiotalar or tibiotalocalcaneal arthrodesis. The contribution of NMR is very important, as it gives the positive diagnosis as well as information regarding evolution. Complete transverse fractures of the talar neck or body are rare; their treatment only gives a little over one third good and very good results in the long term. NMR gives the diagnosis early and shows the extent of necrosis. It can have predictive value for the collapse risk and guide reeducation with or without weight bearing.     

Therapeutic management of complicated talar extrusion: literature review and case report

Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.     

Nonoperative treatment of closed total talus dislocation without fracture: A case report and literature review

Complete dislocation of the talus not accompanied by a fracture is a very rare injury. Most cases reported are open talus dislocations; closed dislocations are rarely seen. The functional prognosis is poor due to osteonecrosis of the talus which develops in the majority of cases.We present a case of lateral dislocation of the left talus in a 29-year-old road accident victim, but no fracture could be detected in the talus and any of malleolus. Reduction of dislocation had been performed in emergency by external manipulation. At 1-year follow-up, the right ankle was pain free and stable. Motion was satisfactory: 15° dorsal flexion, 30° plantar flexion; the talus didn''t show subluxation and avascular necrosis could not be detected.     

Severe Lisfrancs injuries: primary arthrodesis or ORIF?

Twenty-eight patients, with severe, acute Lisfranc dislocations, requiring operative intervention, were treated between 1989 and 1992 in a level one Trauma Center. Different treatment protocols were used by the two senior staff surgeons. This allowed ORIF to be compared to complete arthrodesis and partial arthrodesis. Twelve patients were treated with primary arthrodesis after open reduction of the dislocation. Partial (5) or complete arthrodesis (6) (depending on the type of fracture) was performed in these 12 patients. Sixteen patients were treated with open reduction and temporary fixation with stabilization and compression screw fixation (ORIF group). The subgroups were identical in age (mean 30.5 years), follow-up (30.1 months), type of fracture, type of injury and time to intervention. Anatomical reduction was achieved in eight of the 12 patients in the arthrodesis groups and in 12 of the 16 patients in the ORIF group. The Baltimore Painful foot Score (PFS) was higher in the ORIF group then in the complete arthrodesis group meaning the ORIF group had less pain. No difference in the PFS was found between the ORIF group and the partial arthrodesis group. Subsequent revision surgery was necessary in two cases in the arthrodesis groups and two cases in the ORIF group. Stiffness of the forefoot, loss of metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. Open reduction and internal fixation with screws or partial arthrodesis is the treatment of choice in severe tarsometatarsal fracture dislocations. Primary complete arthrodesis should be reserved as a salvage procedure.